Predictors of skilled maternal health services utilizations: A case of rural women in Ethiopia

Community-Based Health Education Led by Women's Groups Significantly Improved Maternal Health Service Utilization in Southern Ethiopia: A Cluster Randomized Controlled Trial

OBJECTIVE

This study aimed to evaluate the effect of health education intervention (HEI) on maternal health service utilization (MHSU) in southern Ethiopia.

METHODS

From 10 January to 1 August 2023, a community-based, two-arm, parallel-group cluster randomized controlled trial (cRCT) was conducted among pregnant mothers in the Northern Zone of Sidama National Regional State, Ethiopia. We utilized multilevel mixed-effects modified Poisson regression with robust variance to control for the effects of clustering and potential confounders. The level of significance was adjusted for multiple comparisons.

RESULTS

The overall utilization of at least one antenatal care (ANC) visit was 90.2% in the treatment group and 59.5% in the comparator group (χ2 = 89.22, p < 0.001). Health facility delivery (HFD) utilization was considerably different between the treatment group (74.3%) and the comparator group (50.8%) (χ2 = 70.50, p < 0.001). HEI significantly increased ANC utilization (adjusted risk ratio [ARR]: 1.32; 99% CI: 1.12-1.56) and HFD utilization (ARR: 1.24; 99% CI: 1.06-1.46). The utilization of at least one postnatal care (PNC) service was 65.4% in the treatment group and 52.1% in the comparator group (χ2 = 19.51, p = 0.01). However, after controlling for the effects of confounders and clustering, the impact of HEI on PNC utilization was insignificant between the two groups (ARR: 1.15; 99% CI: 0.89-1.48).

CONCLUSION

A community-based HEI significantly increased ANC and HFD utilization but did not increase PNC utilization. Expanding the HEI with certain modifications will have a superior effect on improving MHSU.

TRIAL REGISTRATION NUMBER

NCT05865873.

Utilization of Antenatal Care and Skilled Birth Delivery Services in Sub-Saharan Africa: A Systematic Scoping Review

Daily, the number of women who die around the world reaches an average of 800; these deaths are a result of obstetric complications in pregnancy and childbirth, and 99% of these deaths occur in low- and middle-income countries. This review probes the use of antenatal care (ANC) and skilled birth delivery (SBD) services in sub-Saharan Africa (SSA) and highlights research gaps using Arksey and O'Malley's methodological approach. The screening of abstracts and full text was carried out by two independent authors who ensured the eligibility of data extraction from the included articles. An exploration of the data was undertaken with descriptive analyses. In total, 350 potentially eligible articles were screened, and 137 studies were included for data extraction and analysis. From the 137 included studies, the majority were from Ethiopia (n = 40, 29.2%), followed by Nigeria (n = 30, 21.9%). Most of the studies were published between 2019 and 2023 (n = 84, 61%). Significant trends and challenges with ANC and SBD services emerged from the studies. It is revealed that there are wide gaps in the utilization of ANC and SBD services. Policy attention, intervention strategies to improve access, resources, rural-urban disparity, and women's literacy are recommended to improve the utilization of ANC and SBD services in SSA countries.

Determinants of anemia level among reproductive-age women in 29 Sub-Saharan African countries: A multilevel mixed-effects modelling with ordered logistic regression analysis

BACKGROUND

Despite the implementation of different nutritional and non-nutritional interventions, 43% of reproductive-age women in Africa suffer from anemia. Recent evidence also shows that none of the Sub-Saharan African (SSA) countries are on the track to achieve the nutrition target of 50% anemia reduction by 2030. To date, information on the level of anemia and its determinants among reproductive-age women at the SSA level is limited. Thus, this study aimed to estimate the pooled prevalence of anemia level and its determinants in SSA countries.

METHODS

We used a pooled data of 205,627 reproductive-age women from the recent demographic and health surveys of 29 SSA countries that were conducted between 2010-2021. A multilevel mixed-effects analysis with an ordered logistic regression model was fitted to identify determinants of anemia level and the deviance value was used to select the best-fitted model. First, bivariable ordinal logistic regression analysis was done and the proportional odds assumption was checked for each explanatory variable using a Brant test. Finally, in a multivariable multilevel ordinal logistic regression model, a p-value<0.05 and AOR with the corresponding 95% CI were used to identify determinants of anemia level. All analyses were done using Stata version 17 software.

RESULTS

The pooled prevalence of anemia among women of reproductive age in SSA was 40.5% [95% CI = 40.2%-40.7%], where 24.8% [95% CI: 24.6%-25.0%], 11.1% [95% CI = 10.9%-11.2%], and 0.8% [95% CI = 0.7%-0.8%] had mild, moderate, and severe anemia, respectively. The prevalence significantly varied from the lowest of 13% in Rwanda to the highest of 62% in Mali, and anemia was found as a severe public health problem (prevalence of ≥ 40%) in 18 countries. The regression result revealed that polygamous marriage, women and husband illiteracy, poor household wealth, shorter birth interval, non-attendance of antenatal care, underweight, unimproved toilet and water facilities, and low community-level women literacy were positively linked with high anemia level. Additionally, the likelihood of anemia was lower in women who were overweight and used modern contraception.

CONCLUSIONS

Overall results showed that anemia among women of reproductive age is a severe public health problem in SSA countries, affecting more than four in ten women. Thus, enhancing access to maternal health services (antenatal care and contraception) and improved sanitation facilities would supplement the existing interventions targeted to reduce anemia. Moreover, strengthening women's education and policies regulating the prohibition of polygamous marriage are important to address the operational constraints.

Effect of optimal antenatal care on maternal and perinatal health in Ethiopia

INTRODUCTION

Receiving at least four antenatal care (ANC) visits have paramount importance on the health of mothers and perinates. In Ethiopia, several studies were conducted on ANC service utilization; however, limited studies quantified the effect of care on maternal and perinate health. In response to this gap, this study is conducted to quantify the effect of optimal ANC care (≥4 visits) on maternal and perinatal health among women who received optimal care in comparison to women who did not receive optimal care.

METHODS

The study utilized the Ethiopian perinatal death surveillance and response (PDSR) system dataset. A total of 3,814 reviewed perinatal deaths were included in the study. Considering the nature of the data, preferential within propensity score matching (PWPSM) was performed to determine the effect of optimal ANC care on maternal and perinatal health. The effect of optimal care was reported using average treatment effects of the treated [ATT].

RESULT

The result revealed that optimal ANC care had a positive effect on reducing perinatal death, due to respiratory and cardiovascular disorders, [ATT = -0.015, 95%CI (-0.029 to -0.001)] and extending intrauterine life by one week [ATT = 1.277, 95%CI: (0.563-1.991)]. While it's effect on maternal health includes, avoiding the risk of having uterine rupture [ATT = -0.012, 95%CI: (-0.018 to -0.005)], improving the utilization of operative vaginal delivery (OVD) [ATT = 0.032, 95%CI: (0.001-0.062)] and avoiding delay to decide to seek care [ATT = -0.187, 95%CI: (-0.354 to -0.021)].

CONCLUSION

Obtaining optimal ANC care has a positive effect on both maternal and perinatal health. Therefore, policies and interventions geared towards improving the coverage and quality of ANC services should be the top priority to maximize the benefit of the care.

Individual- and community-level determinants of maternal health service utilization in southern Ethiopia: A multilevel analysis

BACKGROUND

Maternal health service utilization decreases maternal morbidity and mortality. However, the existing evidence is inadequate to design effective intervention strategies in Ethiopia.

OBJECTIVES

This study aimed to examine the utilization of maternal health service and identify its determinants among women of reproductive age in southern Ethiopia.

DESIGN

A community-based cross-sectional study was conducted from October 21 to November 11, 2022 on a sample of 1140 women selected randomly from the Northern Zone of the Sidama region.

METHODS

Data were collected using the Open Data Kit mobile application and exported to Stata version 15 for analysis. We used a multilevel mixed-effects modified Poisson regression with robust standard error to identify determinants of maternal health service utilization.

RESULTS

Utilization of antenatal care, health facility delivery, and postnatal care was 52.0% (95% confidence interval: 49.0%, 55.0%), 48.5% (95% confidence interval: 45.6%, 51.4%), and 26.0% (95% confidence interval: 23.0%, 29.0%), respectively. Antenatal care use was associated with receiving model family training (adjusted prevalence ratio: 1.19; 95% confidence interval: 1.06, 1.35), knowledge of antenatal care (adjusted prevalence ratio: 1.54; 95% confidence interval: 1.31, 1.81), perceived quality of antenatal care (adjusted prevalence ratio: 1.02; 95% confidence interval: 1.01, 1.03), and having birth preparedness plan (adjusted prevalence ratio: 1.13; 95% confidence interval: 1.02, 1.25). The identified determinants of health facility delivery use were middle wealth rank (adjusted prevalence ratio: 1.35; 95% confidence interval: 1.03, 1.77), perceived quality of health facility delivery (adjusted prevalence ratio: 1.02; 95% confidence interval: 1.01, 1.03), antenatal care (adjusted prevalence ratio: 1.76; 95% confidence interval: 1.36, 2.26), and high community-level women literacy (adjusted prevalence ratio: 1.55; 95% confidence interval: 1.10, 2.19). Postnatal care use was associated with facing health problems during postpartum period (adjusted prevalence ratio: 1.79; 95% confidence interval: 1.18, 2.72), urban residence (adjusted prevalence ratio: 3.52; 95% confidence interval: 2.15, 5.78), knowledge of postnatal care (adjusted prevalence ratio: 1.11; 95% confidence interval: 1.04, 1.19), and low community-level poverty (adjusted prevalence ratio: 0.43; 95% confidence interval: 0.25, 0.73).

CONCLUSION

Maternal health service use was low in the study area and was influenced by individual- and community-level determinants. Any intervention strategies must consider multi-sectorial collaboration to address determinants at different levels. The programs should focus on the provision of model family training, the needs of women who have a poor perception, and knowledge of maternal health service at the individual level.

Determining factors associated with the prevalence of knowledge, attitude, and practice in seeking skilled maternal healthcare services among women in a remote area of Gesha district

Background

Skilled health care is essential for the mother's and newborn's health and well-being during pregnancy, labor, and the postpartum period. This study aimed to analyze women's knowledge, attitudes, and practices while requesting competent assistance for maternity healthcare in Gesha District, Southwest Region of Ethiopia.

Methods

A community-based cross-sectional study design was conducted from September 20, 2021 to October 19, 2021. A total of 424 mothers participated in this study and a systematic sampling technique was used to select the respondents. The data were collected using a pretested and structured questionnaire. Statistical software SPSS-20 and R-4.1.2 were used to enter and analyze the data respectively. The factors associated with the prevalence of Knowledge, Attitude, and Practice in seeking Skilled Maternal Healthcare Services were identified using descriptive analysis and a binary logistic regression model.

Results

This study result revealed that the overall proportions of good knowledge, positive attitude, and good practice in seeking skilled maternal health care services were 39.15%, 37.5%, and 34.67% respectively. Estimated odds of having knowledge, attitude, and practice were as follows: for having age between 20–24 years at first pregnancy 1.859, 1.86, and 1.799; having a plan for pregnancy 2.74,2.315 and 2.579; mothers attended elementary education 2.337, 2.565 and 3.312; having maternal age 20–24 years 4.336,4.989 and 5.870; maternal age 25–29 years 2.917, 3.794 and 4.017; maternal age 35–49 years 2.837, 2.991 and 3.412; having husbands who had attended elementary education level 2.736, 2.542 and 2.134; secondary and above education 3.464, 3.360 and 2.508; rich mothers 2.261, 1.995 and 2.452; having antenatal care 4 times and above 2.606, 2.570, 2.682; having transportation access 1.921, 1.956 and 2.404; having media access 1.979, 2.171 and 2.715 respectively. The odds of having attitude and practice respectively were as follows: married 1.762, and 2.208; having medium wealth index 1.933 and 2.424. The odds of having previous pregnancy complications was 2.147 which significantly affect the practice of seeking skilled maternal care assistance.

Conclusions

This study discovered that the study participants' knowledge, attitude, and practice of skilled maternal health care are low. Associated factors included age at first pregnancy, planned pregnancy, maternal education level, husband’s education level, maternal age, antenatal care service visits, transport access, and access to media were found to significantly affect the knowledge, attitude, and practice of the respondents in seeking skilled maternal care assistance in common. The household wealth index was also associated with attitude. Pregnancy complications, current marital status, and household wealth index also significantly affect the practice of seeking skilled maternal care assistance. As a result of the findings, initiatives to increase women's knowledge, attitudes, and use of expert maternal health services in the research area are needed for women residing in rural areas.

Female education and maternal health care utilization: evidence from Uganda

Background

Maternal health care is among the key indicators of population health and economic development. Therefore, the study attempted to explore female education and maternal healthcare utilization in Uganda. The study identified the causal effect of introduction of free education by exploiting the age as an instrument at the second stage model (BMC Health Serv Res. 2015. 10.1186/s12913-015-0943-8; Matern Child Health J. 2009;14:988–98). This instrument provided an exogenous source of variation in the years of schooling and allowed to implement a regression discontinuity design which accounted for heterogeneity in the cohort overtime.

Methods

The study used the Ordinary Least Squares (OLS) to help predict years of schooling that were used in the second stage model in the Two Stage Least Squares (2SLS). The study further used the Regression Discontinuity Design (RDD) model with a running variable of birth years to observe its effect on education. To control for heterogeneity in regions in the second stage model, a fixed effects model was used.

Results

Female education indeed had a positive impact on maternal health care utilization. It was further found out that age also influences maternal health care utilization.

Conclusions

Therefore, as an effort to improve professional maternal health care utilisation, there is need to focus on education beyond primary level. Uganda Government should also ensure that there is an improvement in community infrastructure and security across all regions and locations.

Maternal health care (MHC) utilization is one of the Millennium Development Goals (SDG) of pursuit. Globally, most low-income countries like Uganda contribute greatly to pregnancy-related mortalities that are largely preventable through adequate utilization of essential maternal health care services. Though Uganda over time has registered some increase in maternal utilization, this has been attributed to a number of factors. This study intended to demonstrate whether the introduction of free primary education in Uganda led to increase in the utilization of maternal health services. To address this, we used Ordinary Least Squares (OLS), Two Stage Least Squares (2SLS), Probit and Regression Discontinuity Design (RDD) models using Demographic Health Survey (DHS) data 2006 and 2011. The study found out that indeed the introduction of free primary education increased the utilization of MHC.

Husband Involvement in Maternal, Neonatal, and Child Health Care among Women who Have a Child Less Than one Year in Gondar City, Northwest Ethiopia, 2021

Background

Improving maternal, neonatal and child health is one of the major components of Sustainable Development Goal and countries implement different strategies to achieve this goal. In spite of this, maternal, neonatal and child mortality remains a public health burden in the developing countries, including Ethiopia. World Health Organization recommend active involvement of men during pregnancy, child birth and the postpartum period as an effective strategy to improve maternal as well as newborn health. Therefore, this study aimed to assess husband involvement in maternal, neonatal and child health care among women who have child less than one year in Gondar city, northwest Ethiopia.

Methods

A community-based cross-sectional study was conducted among 870 married women who have a child less than one year in Gondar city. A cluster sampling technique was employed to select study participants. Data were entered into Epi Data version 4.6 and exported to SPSS version 25 for analysis. Multivariable logistic regression was done and adjusted odds ratio with a 95% confidence interval was used to report the association between covariates and the outcome variable.

Results

Husband involvement in Maternal, Neonatal and Child Health (MNCH) care was 66.2% (95%CI: 63, 69.3). Maternal age (18-25years) and (26-35years), having diploma and above education, husband occupation (government employee), (merchant) and (self-employed), planned pregnancy and cesarean delivery were significantly associated with husband involvement in MNCH care.

Conclusion

In this study, nearly two thirds (66.2%) of women had husband involvement in MNCH care. Therefore, it is important to improve women's educational attainment and actions should be taken to prevent unplanned pregnancy.

Utilization of deworming medication and its associated factors among pregnant married women in 26 sub-Saharan African countries: a multi-country analysis

BACKGROUND

Deworming is one of the strategies to reduce the burden of anemia among pregnant women. Globally, pregnant women in sub-Saharan Africa are more affected by anemia. Therefore, this study examined both the coverage and demographic, socioeconomic, and women empowerment-related factors associated with the utilization of deworming medication among pregnant married women in sub-Saharan Africa.

METHODS

We used data from the most recent Demographic and Health Surveys of 26 countries in sub-Saharan Africa conducted between 2010 and 2019. Using Stata version-14 software, analysis was done on 168,910 pregnant married women. Bivariate and multivariable logistic regression analyses were conducted to examine the factors associated with the utilization of deworming medication. The results were presented using adjusted odds ratios (aORs) at 95% confidence intervals (CIs).

RESULTS

The pooled results showed that about 50.7% (95% CI 48.2-53.3%) of pregnant married women in the studied countries took deworming medications, and this varied from as high as 84.1% in Sierra Leone to as low as 2% in Angola. Regarding sub-regional coverage, the highest and lowest coverages were seen in East Africa (67.6%, 95% CI 66.0-69.1%) and West Africa (24.3%, 95% CI 22.4-26.4%) respectively. We found higher odds of utilization of deworming medication among older pregnant married women (aOR=1.93, 95% CI 1.32-2.84), women with educated husbands (aOR=1.40, 95% CI 1.11-1.77), wealthier women (aOR=3.12, 95% CI 1.95-4.99), women exposed to media (aOR=1.46, 95% CI 1.18-1.80), and those who had four or more antenatal care visits (aOR=1.51, 95% CI 1.24-1.83).

CONCLUSIONS

Enhancing women's education, disseminating information about maternal healthcare services through mass media, and ensuring that women from economically disadvantaged households benefit from national economic growth can be considered as deworming medication improvement strategies in sub-Saharan Africa. Moreover, providing more attention to adolescents or young pregnant women and increasing the number of antenatal care visits could be considered to increase deworming uptake among pregnant married women.